Form SSA-765 Response to Notice of Revised Determination

,SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0347

TOE 710

RESPONSE TO NOTICE OF REVISED DETERMINATION
NAME OF CLAIMANT

SOCIAL SECURITY NUMBER

NAME OF WAGE EARNER OR SELF EMPLOYED PERSON (IF
DIFFERENT FROM CLAIMANT)

SOCIAL SECURITY NUMBER

DO NOT WRITE IN THIS SPACE

SPOUSE'S NAME AND SOCIAL SECURITY NUMBER (COMPLETE ONLY IN SUPPLEMENTAL
SECURITY INCOME CASE)

DISABILITY

SSI

TYPE OF BENEFIT:
WORKER

CHILD

BLIND

CHILD

I wish to appear at a Disability Hearing (includes representative appearing)

YES

NO

I have additional evidence or information to submit

YES

NO

WIDOW

DISABILITY

If "Yes," check as many as appropriate:
EVIDENCE ATTACHED

I WILL FURNISH THE FOLLOWING EVIDENCE: (DESCRIBE)

I cannot furnish any or all additional evidence. I have the following information or sources of evidence to provide:

I NEED AN INTERPRETER

If "Yes," complete
this line
NAME OF REPRESENTATIVE (IF ANY)

YES

CHECK
ONE

LANGUAGE

SSA NEEDS TO PROVIDE
INTERPRETER

REPRESENTATIVE'S ADDRESS

NO
I WILL PROVIDE
INTERPRETER

TELEPHONE NUMBER
(INCLUDE AREA CODE)

SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)

DATE (MONTH, DAY, YEAR)

SIGN
HERE

TELEPHONE NUMBER
(INCLUDE AREA CODE)

MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, OR RURAL ROUTE)
CITY AND STATE

ZIP CODE

Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (NUMBER AND STREET, CITY, STATE ZIP CODE)

ADDRESS (NUMBER AND STREET, CITY, STATE ZIP CODE)

Form SSA-765 (6-89) Use Prior Editions EF (05-2002)

(See information on reverse)

PRIVACY ACT NOTICE: The Social Security.Administration is authorized to collect the information on this form
under regulation 20 CFR 404.992 and 416.1492. Giving us the information on this form is voluntary. However, if
you do not respond, we will make a decision based on the evidence in your file.
The Social Security Administration will use the information on this form to fully evaluate your claim for disability
benefits. We may routinely give out the information on this form without your consent if:
1. We need to get more information to decide if you are eligible for benefits;
2. An agency needs this information to decide if you are eligible for a health or income program such as SSI
State supplementary payments, food stamps, Medicaid, energy assistance, Veterans benefits, or Basic
Educational Opportunity Grants;
3. A Federal law requires that we give out this information;
4. Your Congressman or the President's office needs this information to answer questions you ask them;
5. Someone needs this information to do statistical research or audit reports for us related to the Social
Security programs, or;
6. The Department of Justice needs the information to represent the Federal Government in a court suit related
to SSA administered programs.
These and other reasons why information about you may be used or given out are explained in the Federal Register.
If you would like more information about this, get in touch with any Social Security office.

Computer Matching Statement: We may also use the information you give us when we match records by
computer. Matching programs compare our records with those of other Federal, State or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information about you may be used or given out are available in
Social Security offices. If you want to learn more about this, contact any Social Security office.

PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C. §3507,
as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take you
about 30 minutes to read the instructions, gather the necessary facts, and answer the questions.

See below for
revised PRA and
PA statments.

Form SSA-765 (6-89) (Back) EF (05-2002)

Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) and 1631(e)(1)(A) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to fully evaluate your claim for
disability benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information will result in us making a decision based on evidence in your file.
We rarely use the information you supply for any purpose other than to evaluate your claim for
disability benefits. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, state, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for federally-funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice
entitled, Claims Folders Systems, 60-0089. This notice, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about
30 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.